Barrett, Brock et al v. Itstein, Joe et al
Filing
3
ORDER directing plaintiffs to submit either the $400 filing fee or Financial Affidavits by 8/28/2017. Signed by Magistrate Judge Peter A. Oppeneer on 8/4/2017. (jef),(ps)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
BROCK B. BARRETT AND SUZANNE A.
(HOGAN) KENT-BARRETT,
ORDER
Plaintiffs,
v.
Case No. 17-cv-610-jdp
JOE ITSTEIN, et al.
Defendants.
Plaintiffs Brock B. Barrett and Suzanne A. (Hogan) Kent-Barrett have filed a
proposed civil complaint. Plaintiffs have not paid the $400 filing fee nor asked for leave to
proceed without prepayment of fees or costs. In the event that plaintiffs wish to proceed
without prepayment of the filing fee, the enclosed affidavits must be completed to determine
whether plaintiffs qualify as indigent.
ORDER
IT IS ORDERED that plaintiff Brock B. Barrett and Suzanne A. (Hogan) KentBarrett may have until August 28, 2017, in which to either pay the $400 filing fee or to
submit the enclosed affidavits of indigency and return them to the court. If, by August 28,
2017, plaintiffs fail to respond to this order, I will assume that plaintiffs wishes to withdraw
this action voluntarily. In that event, the case will be closed without prejudice to plaintiffs
filing the case at a later date.
Entered this 4th day of August, 2017.
BY THE COURT:
/s/
PETER OPPENEER
Magistrate Judge
UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
SUZANNE A. (HOGAN KENT-BARRETT
Plaintiffs,
v.
ORDER
JOE ITSTEIN, et al.
Case No. 17-cv-610-jdp
Defendants.
NON-PRISONER REQUEST TO PROCEED IN DISTRICT COURT
WITHOUT PREPAYING THE FILING FEE
Answer the following questions to the best of your ability.
Note: If you do not tell the truth, the court may dismiss your lawsuit.
I.
Personal Information
1)
Are you employed?
□Yes
□ No
2)
Are you married?
If “Yes,” is your spouse employed?
□ Yes
□ Yes
□ No
□ No
3)
Do you have any dependents that you are responsible for supporting?
□ Yes
□ No
If “Yes,” list them below:
Name or initials (for
minor children only)
Relationship to You
Age
Amount of Support
Provided per Month
________________________
_________________
________
$____________
________________________
_________________
________
$____________
________________________
_________________
________
$____________
II.
Income - If you are married, your answers must include your spouse's income.
(When calculating income, include any wages, salary, rent, child support, public
assistance, unemployment compensation, disability payments, life insurance payments,
pensions, annuities, workers' compensation, stock dividends and interest, gifts and
inheritance, or other money you receive from any source.)
1)
State your total monthly wages or salary?
2)
Provide the name and address of your employer(s):
$ ______________
______________________________________________________________
3)
State your spouse's total monthly wages or salary? $ ______________
State the amount of money you have received from any other source in the last twelve months,
such as the sources listed above. Please attach an additional sheet if necessary.
Source of income
Amount
______________________________________________
$ ______________________
______________________________________________
$ ______________________
III.
Expenses - If you are married or have dependents, your expenses should also include
your household's expenses.
(When calculating household expenses, you may include groceries, clothing, medical
costs, utilities that are not included in your rental payments, transportation, and
insurance.)
1)
Identify the following amounts that you pay per month:
□ Rent or
□ Mortgage
$ __________________________________
Car payment(s)
$ __________________________________
Alimony or court-ordered child support
$ __________________________________
Credit card payment(s)
$ __________________________________
2)
Do you have any other monthly expenses that you have not already listed?
□ Yes
□ No
If “Yes,” list them below:
Expense
Amount
____________________________
$ __________________________________
____________________________
$ __________________________________
____________________________
$ __________________________________
3)
What are your total monthly expenses?
$___________________________________
IV.
Property - If you are married, your answers must include your spouse's property.
1)
Do you own a car?
□ Yes
□ No
If “Yes,” list car(s) below:
Make and Model
Year
Approximate Current
Value
_______________________________________________ __________
$________________
_______________________________________________ __________
$________________
2)
Do you own your home(s)?
□ Yes
If “Yes,” state the approximate value(s).
□ No
$ ____________________
What is the amount of equity (assessed value of residence minus outstanding
mortgage balance) in the home(s)? $ ____________________
3)
Do you have any cash or checking, savings, or other similar accounts?
□ Yes
□ No
If “Yes,” state the total of such sums.
$_____________________________
4)
Do you own any other property of value, such as real estate, stocks, bonds, trusts, or
individual retirement accounts (e.g., IRA, 401 k), artwork or jewelry?
□ Yes
□ No
If “Yes,” describe the property and the approximate value(s).
________________________________________________________________
V.
Other Circumstances - Describe any other financial circumstance(s) that you would like
the court to consider when reviewing this petition.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
I, ____________________, declare that I am the plaintiff bringing this complaint. I
declare that I am unable to prepay the fee and that I am entitled to the relief sought in the
complaint.
___________________________
Date
_________________________________________
Signature - Signed Under Penalty of Perjury
UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
BROCK B. BARRETT
Plaintiffs,
v.
ORDER
JOE ITSTEIN, et al.
Case No. 17-cv-610-jdp
Defendants.
NON-PRISONER REQUEST TO PROCEED IN DISTRICT COURT
WITHOUT PREPAYING THE FILING FEE
Answer the following questions to the best of your ability.
Note: If you do not tell the truth, the court may dismiss your lawsuit.
I.
Personal Information
1)
Are you employed?
□Yes
□ No
2)
Are you married?
If “Yes,” is your spouse employed?
□ Yes
□ Yes
□ No
□ No
3)
Do you have any dependents that you are responsible for supporting?
□ Yes
□ No
If “Yes,” list them below:
Name or initials (for
minor children only)
Relationship to You
Age
Amount of Support
Provided per Month
________________________
_________________
________
$____________
________________________
_________________
________
$____________
________________________
_________________
________
$____________
II.
Income - If you are married, your answers must include your spouse's income.
(When calculating income, include any wages, salary, rent, child support, public
assistance, unemployment compensation, disability payments, life insurance payments,
pensions, annuities, workers' compensation, stock dividends and interest, gifts and
inheritance, or other money you receive from any source.)
1)
State your total monthly wages or salary?
2)
Provide the name and address of your employer(s):
$ ______________
______________________________________________________________
3)
State your spouse's total monthly wages or salary? $ ______________
State the amount of money you have received from any other source in the last twelve months,
such as the sources listed above. Please attach an additional sheet if necessary.
Source of income
Amount
______________________________________________
$ ______________________
______________________________________________
$ ______________________
III.
Expenses - If you are married or have dependents, your expenses should also include
your household's expenses.
(When calculating household expenses, you may include groceries, clothing, medical
costs, utilities that are not included in your rental payments, transportation, and
insurance.)
1)
Identify the following amounts that you pay per month:
□ Rent or
□ Mortgage
$ __________________________________
Car payment(s)
$ __________________________________
Alimony or court-ordered child support
$ __________________________________
Credit card payment(s)
$ __________________________________
2)
Do you have any other monthly expenses that you have not already listed?
□ Yes
□ No
If “Yes,” list them below:
Expense
Amount
____________________________
$ __________________________________
____________________________
$ __________________________________
____________________________
$ __________________________________
3)
What are your total monthly expenses?
$___________________________________
IV.
Property - If you are married, your answers must include your spouse's property.
1)
Do you own a car?
□ Yes
□ No
If “Yes,” list car(s) below:
Make and Model
Year
Approximate Current
Value
_______________________________________________ __________
$________________
_______________________________________________ __________
$________________
2)
Do you own your home(s)?
□ Yes
If “Yes,” state the approximate value(s).
□ No
$ ____________________
What is the amount of equity (assessed value of residence minus outstanding
mortgage balance) in the home(s)? $ ____________________
3)
Do you have any cash or checking, savings, or other similar accounts?
□ Yes
□ No
If “Yes,” state the total of such sums.
$_____________________________
4)
Do you own any other property of value, such as real estate, stocks, bonds, trusts, or
individual retirement accounts (e.g., IRA, 401 k), artwork or jewelry?
□ Yes
□ No
If “Yes,” describe the property and the approximate value(s).
________________________________________________________________
V.
Other Circumstances - Describe any other financial circumstance(s) that you would like
the court to consider when reviewing this petition.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
I, ____________________, declare that I am the plaintiff bringing this complaint. I
declare that I am unable to prepay the fee and that I am entitled to the relief sought in the
complaint.
___________________________
Date
_________________________________________
Signature - Signed Under Penalty of Perjury
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